Archive for category Plateau

The rehabilitation process throughout the first several months of stroke recovery can be confusing and often daunting, with peaks and valleys that either encourage or slow the healing process. Varying levels of paralysis are common, and adjusting to ongoing therapy requires a shift in mindset and a complete lifestyle overhaul.

Yet, some of the most significant improvements often occur during these early days, reflecting the initial plasticity of the brain. Therefore, gaining momentum during this neurologically progressive time is key to facing the often-frustrating period ahead—a stage known as a plateau. During this stage, it may feel as if the initial spike in progress was the end of successful rehabilitation and that no further improvement is possible. But for some, the plateauing phase is quite common and even to be expected, and understanding this will help both the patient and caregivers to avoid losing hope, motivation, and persistence during this difficult time.

Are plateaus real?

Over the past two decades, research has reaffirmed the frequency and common intricacies of plateauing in newer stroke patients. In the past, it was more likely for doctors to assume that patients only regained motor function in the first few months after a stroke, and that once the plateau occurred, ongoing exercises and therapy were ineffective.

However, recently published reports now show that patients can regain motor recovery and function up to 23 years after a stroke. Medical professionals are now finding that this complex recovery period often continues to occur for months and even years after a patient has left rehab—and primarily resumes only if patients and caretakers build a recovery planand have access to evidence-based technology to prevent the plateau phase after leaving traditional rehabilitation. Designing a home-exercise program, often by upgrading the previous inpatient therapeutic regimen, is the key to maintaining progress or restarting growth if the plateau phase has begun.

What causes a plateau?

When a stroke occurs, a specific area of the brain suffers an infarction, obstructing the blood supply and killing the functionality of a section of the brain. Though this specific area is not recoverable, the area directly surrounding the infarction-impacted region still holds potential for rehabilitation. In the moments directly after the stroke, however, the area simply does not work.

During the initial healing phase known as the subacute phase, which is usually the first three to six months after the stroke, the most consistent and encouraging signs of progress occur in these regions. This natural healing stage often takes place when patients are being coached along in rehab; but if the plateau stage occurs towards the end of the natural healing phase, it’s common for patients to be sent home for a shift in care.

For this group of patients, this is a difficult transition for several reasons: familiar exercises must be altered and adjusted, the home routine requires greater adaptability, and patients face the discouragement of no longer seeing an uptick in progress, often deterring patients and caretakers from pushing on. Progressing through the discouragement is more easily accomplished when patients and caretakers understand the plateau stage. A solid plan of ongoing, managed care is necessary for continuing to bolster the still-developing parts of the mind.

It’s not the patients that have plateaued, rather treatment options have plateaued them.

It is important to keep in mind that traditional therapy that isn’t evidence-based can be ineffective and can actually causea plateau. Sometimes a patient’s recovery is only as good as the therapist, and if the therapist isn’t modifying the treatment to the patient’s specific needs and incorporating the latest proven interventions because they haven’t been trained or educated, the patient will most likely plateau. If the therapist is well educated on the latest advances and interventions in stroke recovery the patient has a much better chance of avoiding the plateau phase. So, a plateau phase may not be an absolute, it’s a possibility.

How can you overcome a plateau?

After reassuring research, the medical community confirms that working with a managed care professional with a series of ongoing exercises does promote improvement in a stroke patient’s long-term recovery. When signs of recovery seem to stall altogether, here are a few common practices for jumpstarting at-home care.

Saebo Rehabilitation Devices

The brain’s cortical plasticity is a key component in this stage of recovery, and Saebo offers several tools for employing this factor. Motor function and utilization of the hands can be continuously developed with the assistance of the SaeboGlove or SaeboFlex, easing therapy at home with minimal assistance and instruction. The SaeboFlex and SaeboGlove include a proprietary tension system that encourages the extension and grasping strength of the hands of healing stroke patients. This action simultaneously supports brain growth and reprogramming, encouraging the plasticity of the mind through task-oriented exercises.

If patients are unable to functionally use their affected hand, they will develop learned non-use and will eventually reach the plateau phase due to avoidance. The SaeboFlex and and SaeboGlove are two tools that may prevent or minimize the plateau phase and allow patients to engage their affected hand in functional tasks that would otherwise be impossible.

Constraint-Induced Movement Therapy

Similar to the SaeboGlove and SaeboFlex’s use of cortical plasticity, Constraint-Induced Movement Therapy (CIMT) encourages the regrowth of neurological pathways damaged during a stroke. This promotes more meticulous use of the affected hand. By keeping the functional hand from taking full responsibility for daily tasks—usually with a mitt—this method involves preference of the developing side of the brain. Though CIMT is an intensive process, which must be guided and supervised for several-hour stretches at a time, positive results may be seen for years to come.

At-Home Exercises

Maintaining a regimen of exercises that both meets the needs of ongoing recovery and the patient’s comfort is essential to progressing past the plateau stage after traditional rehab. The factor of neuroplasticity allows the brain to constantly adapt, but persistence and regularity is key. When followed correctly, an increase in motor function and strength is probable in many patients. Continuing physical exercise assists with many aspects of the healing process, supporting flexibility, coordination, and balance. Though physical activity does not prevent the occurrence of a second stroke, it will keep the body in key health for recovery.

Staying Motivated

During the difficult transition to home care, supportive family and medical professionals are the vital factor in helping patients maintain motivation and feel guided toward success. As a patient is just beginning the rehabilitation process, it is almost solely in the hands of the assistant to set the tone of the session, and this mutual understanding will drive the exercises forward, making it easier to set and meet small goals along the way. Roadblocks and frustrations are common, but with a structured and steady plan, these stages will pass and times of progress will return.

Handling Emotional Changes

When difficult emotions arise, it is crucial to realize that this is completely normal. Stroke recovery is a long, often slow process, and frustration, anger, and depression are understandable obstacles to encounter. Know that these feelings and physical plateaus will pass with time when both patients and caretakers allow themselves self-care and patience. It is also helpful for families to keep this in mind, as maintaining a genuinely flexible and positive atmosphere during rehabilitation will help all parties see these changes and efforts as a long-term process.

Keep Moving Forward

When heading into long-term stroke treatment, awareness of evidence-based treatment interventions may prevent or decrease the plateauing stage. But with consistent at-home tools and exercises, progress will return, even if it feels slower than in previous phases. The recently damaged brain is taking the necessary time to heal and regrow, and this requires setting short-term goals and celebrating small victories. Reaching the plateau stage is an opportunity to reconsider the next best way forward with your therapist—progress is still ahead, even if the methods and system require a new outlook.

Like this:

Much can be learned from case studies of individual patients. This has been shown more than once in the field of stroke research. The observations by the illustrious neuroanatomist Dr. Brodal of his own stroke are an example (Brodal 1973).

A paper recently published in the Journal of Neurophysiology provides another example. It features a case of delayed partial recovery from weakness and paralysis produced by a devastating stroke, with improvements in hand function more than two decades after the initial event (Sörös et al. 2017).

WHAT DID THEY FIND?

In 1979, when the patient was 15 years old, his cervical rib compressed his subclavian artery, such that thrombosis formed back to the innominate artery. Emboli subsequently entered the carotid and vertebrobasilar circulations. A dense left hemiplegia developed with a large right frontoparietal infarction.

No detail of any initial rehabilitation is given but partial use of the left shoulder and elbow, along with the left leg had been regained about 4 months after the stroke. However, minimal recovery occurred in the left hand: it was spastic and useless for 23 years.

When the patient began regular swimming in 2001, he noted finger movements of his left hand. In 2009, he began extra physiotherapy using a spring-loaded orthosis for his left hand. Currently, the patient can use his left hand to pick up small objects like coins.

Functional MR imaging was performed when the second period of recovery had occurred. When the patient repeatedly opened and closed his left hand there was extensive activation in both hemispheres and bilaterally in the cerebellum. In contrast, movements of comparable size and rate made by the unaffected hand (i.e., the right hand) produced only focal activity in the contralateral sensorimotor cortex, supplementary motor area and cerebellum.

SIGNIFICANCE AND IMPLICATIONS

While the case features a rare complication of the thoracic outlet syndrome produced by a cervical rib, it highlights spectacularly the capacity of cortical and cerebellar circuits to be reformed or reactivated in such a way that new functional movements can occur at the distal extremity, i.e. the hand. It is not possible to determine whether the swimming and later rehabilitation caused or even contributed to the surprising improvement. It may have occurred spontaneously. Nonetheless, the case has important messages for rehabilitation of stroke, especially in young people. The traditional view in rehabilitation following stroke is that most of the functional improvement occurs within the first 12-18 months. One widely promoted view is that the initial motor recovery occurs to a fixed proportion of the initial severity of the deficit (70% of recovery occurs in the first three months) (Prabhakaran et al. 2008; Smith et al. 2017). This case of prolonged paralysis with delayed recovery after a severe ischaemic stroke means that the therapeutic window for improvement can be much longer than traditionally thought. By implication, many new therapies (potentially cellular, pharmacological or physical ones) could be tested long after stroke.

AUTHOR BIO

Simon Gandevia is an NHMRC Senior Principal Research Fellow and Deputy Director of Neuroscience Research Australia (NeuRA). His research investigates the sensorimotor control of human movements. He has special interests in proprioception, muscle, breathing control, and fatigue. He is Chief investigator of the NHMRC Program grant at NeuRA on Motor Impairment. You can learn more about Simon and his research here. You can also follow him on Twitter @SimonGandevia and @MotorImpairment.

It is widely believed that most stroke recovery occurs within 6 months, with little benefit of physiotherapy or other modalities beyond a year. We report a remarkable case of stroke recovery beginning 23 years after a severe stroke due to embolization from the innominate artery and subclavian artery, resulting from compression of the right subclavian artery by a cervical rib. The patient had a large right fronto-parietal infarction with severe left hemiparesis, and a totally non-functional spastic left hand. He experienced some recovery of hand function that began 23 years after the stroke, a year after he took up regular swimming. As a result, intensive physiotherapy was initiated, with repetetive large muscle movement and a spring-loaded mechanical orthosis that provides resistance to finger flexors and supports finger extensors. Within two years he could pick up coins with the previously useless left hand. Functional MRI studies document widespread distribution of the recovery in both hemispheres. This case provides impetus not only to more intensive and prolonged physiotherapy, but also to treatment with emerging modalities such as stem cell therapy, exosome and micro-RNA therapies.

Scientists used to believe that the brain stopped making new brain cells past a certain age. But that believe changed in the late 1990’s as a result of several studies which were performed on mice at the Salk Institute.

After conducting maze tests, neuroscientist Fred H. Gage and his colleagues examined brain samples collected from mice. What they found challenged long standing believes held about neurogenesis, or the creation of new neurons.

To their astonishment, they discovered that the mice were creating new neurons. Their brains were regenerating themselves.

All of the mice showed evidence of neurogenesis but the brains of the athletic mice showed even more.

These mice, the ones that scampered on running wheels, were producing two to three times as many new neurons as the mice that didn’t exercise.

The difference between the mice who performed well on the maze tests and those that floundered was exercise.

That’s great for the mice, but what about humans?

To find out if neurogensis occurred in adult humans, Gage and his colleagues obtained brain tissue from deceased cancer patients who had donated their bodies to research. While still living, these people were injected with the same type of compound used on Gage’s mice to detect new neuron growth. When Gage dyed their brain samples, he saw new neurons. Like in the mice study, they found evidence of neurogenesis – the growth of new brain cells.

From the mice study, it appears that those who exercise produce even more new brain cells than those who don’t. Several studies on humans seem to suggest the same thing.

Studies performed at both the University of Illinois at Urbana- Champaign and Columbia University in New York City have shown that exercise benefits brain function. The test subjects were given aerobic exercises such as walking for at least one hour three times a week. After 6 months they showed significant improvements in memory as measured by a word-recall test. Using fMRI scans they also showed increases in blood flow to the hippocampus (part of the brain associated with memory and learning). Scientists suspect that the blood pumping into that part of the brain was helping to produce fresh neurons.

Dr. Patricia A. Boyle and her colleagues of Rush Alzheimer’s Disease Center in Chicago found that the greater a person’s muscle strength, the lower their likelihood of being diagnosed with Alzheimer’s. The same was true for the loss of mental function that often precedes full-blown Alzheimer’s.

Neuroscientist Gage, by the way, exercises just about every day, as do most colleagues in his field. As Scott Small a neurologist at Columbia explains,

I constantly get asked at cocktail parties what someone can do to protect their mental functioning. I tell them, ‘Put down that glass and go for a run.

So if you want to grow some new brain cells and improve your brain function, go get some exercise!

Abstract

Background. Recovery from stroke is often said to have “plateaued” after 6 to 12 months. Yet training can still improve performance even in the chronic phase. Here we investigate the biomechanics of accuracy improvements during a reaching task and test whether they are affected by the speed at which movements are practiced.

Method. We trained 36 chronic stroke survivors (57.5 years, SD ± 11.5; 10 females) over 4 consecutive days to improve endpoint accuracy in an arm-reaching task (420 repetitions/day). Half of the group trained using fast movements and the other half slow movements. The trunk was constrained allowing only shoulder and elbow movement for task performance.

Results. Before training, movements were variable, tended to undershoot the target, and terminated in contralateral workspace (flexion bias). Both groups improved movement accuracy by reducing trial-to-trial variability; however, change in endpoint bias (systematic error) was not significant. Improvements were greatest at the trained movement speed and generalized to other speeds in the fast training group. Small but significant improvements were observed in clinical measures in the fast training group.

Conclusions. The reduction in trial-to-trial variability without an alteration to endpoint bias suggests that improvements are achieved by better control over motor commands within the existing repertoire. Thus, 4 days’ training allows stroke survivors to improve movements that they can already make. Whether new movement patterns can be acquired in the chronic phase will need to be tested in longer term studies. We recommend that training needs to be performed at slow and fast movement speeds to enhance generalization.

Abstract

Background and Objective: Stroke rehabilitation assumes motor learning contributes to motor recovery, yet motor learning in stroke has received little systematic investigation. Here we aimed to illustrate that despite matching levels of performance on a task, a trained patient should not be considered equal to an untrained patient with less impairment.

Methods: We examined motor learning in healthy control participants and groups of stroke survivors with mild-to-moderate or moderate-to-severe motor impairment. Participants performed a series of isometric contractions of the elbow flexors to navigate an on-screen cursor to different targets, and trained to perform this task over a 4-day period. The speed-accuracy trade-off function (SAF) was assessed for each group, controlling for differences in self-selected movement speeds between individuals.

Results: The initial SAF for each group was proportional to their impairment. All groups were able to improve their performance through skill acquisition. Interestingly, training led the moderate-to-severe group to match the untrained (baseline) performance of the mild-to-moderate group, while the trained mild-to-moderate group matched the untrained (baseline) performance of the controls. Critically, this did not make the two groups equivalent; they differed in their capacity to improve beyond this matched performance level. Specifically, the trained groups had reached a plateau, while the untrained groups had not.

Conclusions: Despite matching levels of performance on a task, a trained patient is not equal to an untrained patient with less impairment. This has important implications for decisions both on the focus of rehabilitation efforts for chronic stroke, as well as for returning to work and other activities.

Exaggerating the visual appearance of mistakes could help people further improve their motor skills after an initial performance peak, according to a new study published inPLOS Computational Biology.

Previous research has shown that manipulating the perception of mistakes can improve motor skills. Dagmar Sternad, Christopher Hasson and colleagues from Northeastern University in Boston and Hokkaido University in Japan set out to examine whether this strategy could further enhance skills after they plateau.

In the study, 42 healthy participants learned a virtual tetherball-like game in which they tried to hit a target with a ball hanging from a pole. After three days, all players reached a performance plateau. Then, for some players, the researchers secretly manipulated the game so that the distance by which the ball missed the target appeared bigger on screen than it actually was.

Participants whose mistakes appeared at least twice as bad as they really were broke past their plateau and continued sharpening their tetherball skills. A control group that remained undeceived showed negligible improvement.

By analyzing the players’ actions using computational learning models, the researchers found that error exaggeration did not change how they made corrections in their throwing techniques. Instead, it reduced random fluctuations, or noise, in nervous system signals that control muscle movement. These findings challenge existing assumptions that such noise cannot be reduced.

The authors point out that their results could help improve strategies to aid people who have reached a motor skills plateau, including elite athletes, healthy elders, stroke patients, and children with dystonia. Future research could reveal the physiological mechanisms underlying the findings.

This work was supported by the National Institute of Child Health and Human Development (NICHD) R01 HD045639, National Institute on Aging (NIA) 1F32 AR061238, National Science Foundation NSF-DMS 0928587, and the U.S. Army Research Institute for the Behavioral and Social Sciences (W5J9CQ-12-C-0046). DS was also supported by a visiting scientist appointment at the Max-Planck Institute for Intelligent Systems in Tübingen, Germany. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the funding organizations. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

BACKGROUND: Long-term outcomes after TBI are examined to a large extent, butlongitudinal studies with more than 1-year follow-up time after injury have beenfewer in number. The course of recovery may vary due to a number of factors and it is still somewhat unclear which factors are contributing.

AIM: The aim of this study was to describe the functional level at four time points up to 24 months after traumatic brain injury (TBI) and to evaluate the predictive impact of pre-injury and injury-related factors.

METHODS: The patients with TBI were examined with Functional Independence Measure(FIM) and Glasgow Outcome Scale Extended (GOSE) at 3 months, 12 months and 24months after injury. Possible predictors were analysed in a regression modelusing FIM total score at 24 months as the outcome measure.

RESULTS: FIM scores improved significantly from rehabilitation unit discharge to 24 months after injury, with peak levels at 3 and 24 months after injury(p < 0.001), for the whole TBI group and the group with severe TBI. The moderateTBI group did not show significant FIM score improvement during this time period. GOSE scores for the whole group and the moderate group improved significantlyover time, but the severe group did not. FIM at admission to the rehabilitation unit and GCS score at admission to the rehabilitation unit were closest to being significant predictors of FIM total scores 24 months after injury (B = 0.265 and2.883, R(2 )= 0.39, p = 0.073, p = 0.081).

CONCLUSION: FIM levels improved during the period from rehabilitation unitdischarge to 3 months follow-up; thereafter, there was a ‘plateauing’ of recovery. In contrast, GOSE ‘plateauing’ of recovery was at 12 months.

CLINICAL REHABILITATION IMPACT: The study results may indicate that two of themost used outcome measures in TBI research are more relevant for assessment of the functional recovery in a sub-acute phase than in later stages of TBI recovery.

The optimal refinement in nerve repair techniques has reached a plateau, making it imperative to continually explore newer avenues for improving the clinical outcome of peripheral nerve regeneration. The aim of this short review is to discuss the role and mechanism of brain plasticity in nerve regeneration, as well as to explore the possible application of this knowledge for improving the clinical outcome following nerve repair.

From: Role of Central Plasticity in the Outcome of Peripheral Nerve Regeneration by Mohanty et al.

An open question in stroke rehabilitation is, if and how chronic patients can still make improvements after they reached a plateau in motor recovery. Previous research has shown that Constraint-Induced Movement Therapy (CIMT) might be effective in treating hemiparesis and supporting functional improvements in chronic patients, but that it might also be associated with higher costs in terms of demand, resources and inconvenience for the patient.

Here, we offer a new therapeutic approach that combines CIMT with a positive reinforcement component. We suggest that this new therapy, called Reinforcement Induced Movement Therapy (RIMT), might be similarly effective as CIMT and could be suitable for a broader population of chronic stroke patients.

We first implemented a computational model to study the potential outcome of different CIMT and RIMT therapy combinations. Then we present the results of an ongoing clinical trial that supports predictions from the model. We conclude that an optimally combined CIMT and RIMT therapy might propose a novel and powerful rehabilitation approach, addressing the specific needs of chronic stroke patients.